Munchausen syndrome by proxy
Munchausen syndrome by proxy (MSbP or MbP) is a behavior pattern akin to Munchausen syndrome (a psychiatric factitious disorder wherein those affected feign disease, illness, or psychological trauma to draw attention, sympathy, or reassurance to themselves) in which a caregiver or spouse fabricates, exaggerates, or induces mental or physical health problems in those who are in their care, usually to gain attention or sympathy from others. With deception at its core, this behavior is an elusive, potentially lethal, and frequently misunderstood form of child abuse or medical neglect that has been difficult to define, detect, and confirm.
MSbP has also spawned much heated controversy within the legal and social services communities. In a handful of high-profile cases, mothers who have had several children die from sudden infant death syndrome have been declared to have MSbP. Based on MSbP testimony of an expert witness, they were tried for murder, convicted, and imprisoned for several years. In some cases, that testimony was later impeached, resulting in exoneration of those defendants.
Signs and symptoms
In Munchausen syndrome by proxy, an adult caregiver makes a child or elderly person appear mentally or physically ill or impaired by either fabricating symptoms or actually causing harm to the child or elderly person to gain the attention of medical providers and others. To perpetuate the medical relationship, the caregiver systematically misrepresents symptoms, fabricates signs, manipulates laboratory tests, or even purposely harms the child (e.g. by poisoning, suffocation, infection, physical injury). Studies have shown a mortality rate of between 6% and 10% of MSbP victims, making it perhaps the most lethal form of abuse.
A review found the average age of the person affected at diagnosis was 4 years; slightly over half of them were aged 24 months or younger, and 75% were under six years old. The average duration from onset of symptoms to diagnosis was 22 months. Six percent were dead, mostly from apnea (a common result of smothering) or starvation and 7% suffered long-term or permanent injury. About half of them had siblings; 25% of the known siblings were dead, and 61% of siblings had symptoms similar to the victim or that were otherwise suspicious. The mother was the perpetrator in 76.5% of the cases, the father in 6.7%.
In the above study, most presented with about three medical problems in some combination out of 103 different reported symptoms. The most frequently reported problems are apnea (26.8% of cases), anorexia / feeding problems (24.6% of cases), diarrhea (20%), seizures (17.5%), cyanosis (blue skin) (11.7%), behavior (10.4%), asthma (9.5%), allergy (9.3%), and fevers (8.6%). Other symptoms include failure to thrive, vomiting, bleeding, rash and infections. Many of these symptoms are easy to fake because they are subjective. For example, reports that "my baby had a fever last night" are impossible to prove or disprove. The number and variety of presented symptoms contributes to the difficulty in reaching a proper MSbP diagnosis.
The primary distinguishing feature that differentiates MSbP from "typical" physical child abuse is the degree of premeditation involved. Whereas most physical abuse entails lashing out at a child in response to some behavior (e.g., crying, bedwetting, spilling food), assaults on the MSbP victim tend to be unprovoked and planned.
Also unique to this form of abuse is the role that health care providers play by actively, albeit unintentionally, enabling the abuse. By reacting to the concerns and demands of perpetrators, medical professionals are manipulated into a partnership of child maltreatment. Challenging cases that defy simple medical explanations may prompt health care providers to pursue unusual or rare diagnoses, thus allocating even more time to the child and the abuser. Even without prompting, medical professionals may be easily seduced into prescribing diagnostic tests and therapies that are at best uncomfortable and costly, and at worst potentially injurious to the child. If the health practitioner instead resists ordering further tests, drugs, procedures, surgeries, or specialists, the MSbP abuser makes the medical system appear negligent for refusing to help a poor sick child and their selfless parent. Like those with Munchausen syndrome, MSbP perpetrators are known to switch medical providers frequently, until they find one that is willing to meet their level of need; this practice is known as "doctor shopping" or "hospital hopping".
The perpetrator continues the abuse, because maintaining the child in the role of patient satisfies the abuser's needs. The cure for the victim is to separate the child completely from the abuser. When parental visits are allowed, sometimes there is a disastrous outcome for the child. Even when the child is removed, the perpetrator may then abuse another child: a sibling or other child in the family.
More recently a psychiatric form of MSbP has been postulated – Psychiatric Munchausens Syndrome By Proxy – which involves the presentation of a psychiatric disorder in the child.
Munchausen by Proxy can also have many long-term emotional effects on a child. Depending on their experience of medical interventions, a percentage of victimized children may learn that they are most likely to receive the positive maternal attention they crave when they are playing the sick role in front of health care providers. Several case reports describe Münchausen syndrome patients suspected of themselves having been MSbP victims. Seeking personal gratification through illness can thus become a lifelong and multi-generational disorder in some cases. In stark contrast, other reports suggest survivors of MSbP develop avoidance of medical treatment with post traumatic responses to it. This variation possibly reflects broad statistics on survivors of child abuse in general, where around 30% go on to also become abusers even though a significant percentage do not.
The adult care provider who has abused the child often seems comfortable and not upset over the child's hospitalization. While the child is hospitalized, medical professionals must monitor the caregiver's visits to prevent an attempt to worsen the child's condition. In addition, in many jurisdictions, medical professionals have a duty to report such abuse to legal authorities. Warning signs of the disorder include:
- A child who has one or more medical problems that do not respond to treatment or that follow an unusual course that is persistent, puzzling, and unexplained.
- Physical or laboratory findings that are highly unusual, discrepant with patient's presentation or history, or physically or clinically impossible.
- A parent who appears medically knowledgeable, fascinated with medical details and hospital gossip, appears to enjoy the hospital environment, and expresses interest in the details of other patients' problems.
- A highly attentive parent who is reluctant to leave their child's side and who themselves seem to require constant attention.
- A parent who appears unusually calm in the face of serious difficulties in their child's medical course while being highly supportive and encouraging of the physician, or one who is angry, devalues staff, and demands further intervention, more procedures, second opinions, and transfers to other more sophisticated facilities.
- The suspected parent may work in the health care field themselves or profess interest in a health-related job.
- The signs and symptoms of a child's illness may lessen or simply vanish in the parent's absence (hospitalization and careful monitoring may be necessary to establish this causal relationship).
- A family history of similar or unexplained illness or death in a sibling.
- A parent with symptoms similar to their child's own medical problems or an illness history that itself is puzzling and unusual.
- A suspected emotionally distant relationship between parents; the spouse often fails to visit the patient and has little contact with physicians even when the child is hospitalized with a serious illness.
- A parent who reports dramatic, negative events, such as house fires, burglaries, or car accidents, that affect them and their family while their child is undergoing treatment.
- A parent who seems to have an insatiable need for adulation or who makes self-serving efforts for public acknowledgment of their abilities.
- A patient who inexplicably deteriorates whenever discharge is planned.
Caution is required in the diagnosis of MSbP/FII/FDP. Many of the items above are also indications of a child with organic, but undiagnosed illness. An ethical diagnosis of MSbP must include an evaluation of the child, an evaluation of the parents, and an evaluation of the family dynamics. Diagnoses based only on a review of the child's medical chart can be rejected in court.
Munchausen syndrome by proxy is a controversial term. In the World Health Organization's International Statistical Classification of Diseases, 10th Revision (ICD-10), the official diagnosis is factitious disorder (301.51 in ICD-9, F68.12 in ICD-10). Within the United States, factitious disorder imposed on another (FDIA or FDIoA) was officially recognized as a disorder in 2013, while in the United Kingdom, it is known as fabricated or induced illness by carers (FII),.
- Factitious disorder imposed on self – (formerly Munchausen syndrome).
- Factitious disorder imposed on another – (formerly Munchausen syndrome by proxy); diagnosis assigned to the perpetrator; the victim may be assigned an abuse diagnosis (e.g. child abuse).
Still widely used, the term "Munchausen syndrome by proxy" has led to much confusion in the literature. In the United States, the term has never officially been included as a discrete mental disorder by the American Psychiatric Association, which publishes the widely recognized Diagnostic and Statistical Manual of Mental Disorders (DSM), now in its fifth edition. Although the DSM-III (1980) and DSM-III-R (1987) included Munchausen Syndrome, they did not include MSbP. DSM-IV (1994) and DSM-IV-TR (2000) added MSbP as a proposal only, and finally being recognized as a disorder in DSM-5 (2013) – yet each of these last three editions of the DSM listed this disorder (or proposal) with a different name.
Elsewhere as well, ongoing lack of consensus has led to much confusion over terminology, and MSbP has been given many names in different places and at different times. What follows is a partial list of alternative names that have been either used or proposed (with approximate dates):
- Factitious Disorder Imposed on Another (current) (U.S., 2013) American Psychiatric Association, DSM-5
- Factitious Disorder by Proxy (FDP, FDbP) (proposed) (U.S., 2000) American Psychiatric Association, DSM-IV-TR
- Fictitious Disorder by Proxy (FDP, FDbP) (proposed) (U.S., 1994) American Psychiatric Association, DSM-IV
- Fabricated or Induced Illness by Carers (FII) (U.K., 2002) The Royal College of Paediatrics and Child Health
- Factitious Illness by Proxy (1996) World Health Organization
- Pediatric Condition Falsification (PCF) (proposed) (U.S., 2002) American Professional Society on the Abuse of Children proposed this term to diagnose the child/victim; Perpetrator (mother) would be diagnosed "Factitious disorder by proxy"; MSbP would be retained as the name applied to the 'disorder' that contains these two elements, a diagnosis in the child and a diagnosis in the caretaker.
- Induced Illness (Munchausen Syndrome by Proxy) (Ireland, 1999–2002) Department of Health and Children
- Meadow's Syndrome (1984–1987) named after Roy Meadow. This label, however, had already been in use since 1957 to describe a completely unrelated and rare form of cardiomyopathy.
- Polle Syndrome (1977–1984) Coined by Burman and Stevens, from the then common belief that Baron Münchhausen's second wife gave birth to a daughter named Polle during their marriage. The baron declared that the baby was not his, and the child died from "seizures" at the age of 10 months. The name fell out of favor after 1984, when it was discovered that Polle was not the baby's name, but rather was the name of her mother's hometown.
The definition of the disorder has also been subject to controversy and confusion. For example, while it initially included only the infliction of harmful medical care, the appellation has subsequently been extended to include cases in which the only harm arose from medical neglect, noncompliance, or even educational interference.
One study showed that in 93 percent of MSbP cases, the abuser is the mother or another female guardian or caregiver. This may be attributed to the prevalent socialization pattern that places females in the primary care-taking role. A psychodynamic model of this kind of maternal abuse exists.
MSbP may be more prevalent in the parents of those with a learning difficulty or mental incapacity, and as such the apparent patient could in fact be an adult.
Fathers and other male caregivers have been the perpetrators in only 7% of the cases studied. When they are not actively involved in the abuse, the fathers or male guardians of MSbP victims are often described as being distant, emotionally disengaged, and powerless. These men play a passive role in MSbP by being frequently absent from the home and rarely visiting the hospitalized child. Usually, they vehemently deny the possibility of abuse, even in the face of overwhelming evidence or their child's pleas for help.
Overall, male and female children are equally likely to be the victim of MSbP. In the few cases where the father is the perpetrator, however, the victim is three times more likely to be male.
Society and culture
The name "Munchausen syndrome by proxy" (MSbP) is derived from Munchausen syndrome, a different though related condition. People with Munchausen syndrome have a profound need to assume the sick role, and exaggerate complaints, falsify tests, or inflict illnesses on themselves directly. Munchausen syndrome by proxy perpetrators, by contrast, are willing to fulfill their need for positive attention by hurting their own child, thereby assuming the sick role onto their child, by proxy. These proxies then gain personal attention and support by taking on this fictitious "hero role" and receive positive attention from others, by appearing to care for and save their so-called sick child. Both are named after Baron Munchausen, a literary character based on Hieronymus Karl Friedrich, Freiherr von Münchhausen (1720–1797), a German nobleman and well known storyteller. In 1785, writer and con artist Rudolf Erich Raspe anonymously published a book in which a fictional version of "Baron Munchausen" tells fantastic and impossible stories about himself, establishing a popular literary archetype of a bombastic exaggerator.
The term "Munchausen syndrome by proxy" was first coined by John Money and June Faith Werlwas in a 1976 paper titled Folie à deux in the parents of psychosocial dwarfs: Two cases to describe the abuse-induced and neglect-induced symptoms of the syndrome of abuse dwarfism. That same year, Sneed and Bell wrote an article titled The Dauphin of Munchausen: factitious passage of renal stones in a child.
According to other sources, the term was created by the British pediatrician Roy Meadow in 1977. In 1977, Roy Meadow — then professor of pediatrics at the University of Leeds, England — described the extraordinary behavior of two mothers. According to Meadow, one had poisoned her toddler with excessive quantities of salt. The other had introduced her own blood into her baby's urine sample. This second case occurred during a series of Outpatient visits to the Paediatric Clinic of Dr Bill Arrowsmith at Doncaster Royal Infirmary. He referred to this behavior as Munchausen syndrome by proxy (MSbP).
The medical community was initially skeptical of MSbP's existence, but it gradually gained acceptance as a recognized condition. There are now more than 2,000 case reports of MSbP in the professional literature. Reports come from developing countries, as well as the U.S., with one case from 2012–2013, in Orlando, Florida, and the most recent in Westchester, New York, in early 2015. Other reports come from Sri Lanka, Nigeria, and Oman.
During the 1990s and early 2000s, Meadow was an expert witness in several murder cases involving MSbP/FII. Dr. Meadow was knighted for his work for child protection, though later, his reputation, and consequently the credibility of MSbP, became severely damaged when several convictions of child killing, in which he acted as an expert witness, were overturned. The mothers in those cases were wrongly convicted of murdering two or more of their children, and had already been imprisoned for up to six years.
The pivotal case was that of Sally Clark. Clark was a lawyer wrongly convicted in 1999 of the murder of her two baby sons, largely on the basis of Meadow's evidence. As an expert witness for the prosecution, Meadow asserted that the odds of there being two unexplained infant deaths in one family were one in 73 million. That figure was crucial in sending Clark to jail but was hotly disputed by the Royal Statistical Society, who wrote to the Lord Chancellor to complain. It was subsequently shown that once other factors (e.g. genetic or environmental) were taken into consideration, the true odds were much greater, i.e., there was a significantly higher likelihood of two deaths happening as a chance occurrence than Meadow had claimed during the trial. Those odds in fact range from a low of 1:8500 to as high as 1:200. It emerged later that there was clear evidence of a Staphylococcus aureus infection that had spread as far as the child's cerebrospinal fluid. Clark was released in January 2003 after three judges quashed her convictions in the Court of Appeal in London, but suffering from catastrophic trauma of the experience, she later died from alcohol poisoning. Meadow was involved as a prosecution witness in three other high-profile cases resulting in mothers being imprisoned and subsequently cleared of wrongdoing — those of Trupti Patel, Angela Cannings, and Donna Anthony.
In 2003, Lord Howe, the Opposition spokesman on health, accused Meadow of inventing a "theory without science" and refusing to produce any real evidence to prove that Munchausen syndrome by proxy actually exists. It is important to distinguish between the act of harming a child, which can be easily verified, and motive, which is much harder to verify and which MSbP tries to explain. For example, a caregiver may wish to harm a child out of malice and then attempt to conceal it as illness to avoid detection of abuse, rather than to draw attention and sympathy.
The distinction is often crucial in criminal proceedings, in which the prosecutor must prove both the act and the mental element constituting a crime to establish guilt. In most legal jurisdictions, a doctor can give expert witness testimony as to whether a child was being harmed but cannot speculate regarding the motive of the caregiver. FII merely refers to the fact that illness is induced or fabricated and does not specifically limit the motives of such acts to a caregiver's need for attention and/or sympathy.
In all, around 250 cases resulting in conviction in which Meadow was an expert witness were reviewed, with few changes. Meadow was investigated by the British General Medical Council over evidence he gave in the Sally Clark trial. In July 2005, the GMC declared Meadow guilty of "serious professional misconduct", and he was struck off the medical register for giving "erroneous" and "misleading" evidence. At appeal, High Court judge Mr. Justice Collins said that the severity of his punishment "approaches the irrational" and set it aside.
Collins's judgment raises important points concerning the liability of expert witnesses — his view is that referral to the GMC by the losing side is an unacceptable threat and that only the Court should decide whether its witnesses are seriously deficient and refer them to their professional bodies.
In addition to the controversy surrounding expert witnesses, an article appeared in the forensic literature that detailed legal cases involving controversy surrounding the murder suspect. The article provides a brief review of the research and criminal cases involving Munchausen syndrome by proxy in which psychopathic mothers and caregivers were the murderers. It also briefly describes the importance of gathering behavioral data, including observations of the parents who commit the criminal acts. The article references the 1997 work of Southall, Plunkett, Banks, Falkov, and Samuels, in which covert video recorders were used to monitor the hospital rooms of suspected MSbP victims. In 30 out of 39 cases, a parent was observed intentionally suffocating their child; in two they were seen attempting to poison a child; in another, the mother deliberately broke her 3-month-old daughter's arm. Upon further investigation, those 39 patients, ages 1 month to 3 years old, had 41 siblings; 12 of those had died suddenly and unexpectedly. The use of covert video, while apparently extremely effective, raises controversy in some jurisdictions over privacy rights.
In most legal jurisdictions, doctors are allowed to give evidence only in regard to whether the child is being harmed. They are not allowed to give evidence in regard to the motive. Australia and the UK have established the legal precedent that MSbP does not exist as a medico-legal entity.
As the term factitious disorder (Munchausen's Syndrome) by proxy is merely descriptive of a behaviour, not a psychiatrically identifiable illness or condition, it does not relate to an organised or recognised reliable body of knowledge or experience. Dr Reddan's evidence was inadmissible.
The Queensland Supreme Court further ruled that the determination of whether or not a defendant had caused intentional harm to a child was a matter for the jury to decide and not for the determination by expert witnesses:
The diagnosis of Doctors Pincus, Withers, and O'Loughlin that the appellant intentionally caused her children to receive unnecessary treatment through her own acts and the false reporting of symptoms of factitious disorder (Munchausen Syndrome) by proxy is not a diagnosis of a recognised medical condition, disorder, or syndrome. It is simply placing her within the medical term used in the category of people exhibiting such behavior. In that sense, their opinions were not expert evidence because they related to matters that could be decided on the evidence by ordinary jurors. The essential issue as to whether the appellant reported or fabricated false symptoms or did acts to intentionally cause unnecessary medical procedures to injure her children was a matter for the jury's determination. The evidence of Doctors Pincus, Withers, and O'Loughlin that the appellant was exhibiting the behavior of factitious disorder (Munchausen syndrome by proxy) should have been excluded.
Principles of law and implications for legal processes that may be deduced from these findings are that:
- Any matters brought before a Court of Law should be determined by the facts, not by suppositions attached to a label describing a behavior, i.e., MSBP/FII/FDBP;
- MSBP/FII/FDBP is not a mental disorder (i.e., not defined as such in DSM IV), and the evidence of a psychiatrist should not therefore be admissible;
- MSBP/FII/FDBP has been stated to be a behavior describing a form of child abuse and not a medical diagnosis of either a parent or a child. A medical practitioner cannot therefore state that a person "suffers" from MSBP/FII/FDBP, and such evidence should also therefore be inadmissible. The evidence of a medical practitioner should be confined to what they observed and heard and what forensic information was found by recognized medical investigative procedures;
- A label used to describe a behavior is not helpful in determining guilt and is prejudicial. By applying an ambiguous label of MSBP/FII to a woman is implying guilt without factual supportive and corroborative evidence;
- The assertion that other people may behave in this way, i.e., fabricate and/or induce illness in children to gain attention for themselves (FII/MSBP/FDBY), contained within the label is not factual evidence that this individual has behaved in this way. Again therefore, the application of the label is prejudicial to fairness and a finding based on fact.
The Queensland Judgment was adopted into English law in the High Court of Justice by Mr. Justice Ryder. In his final conclusions regarding Factitious Disorder, Ryder states that:
I have considered and respectfully adopt the dicta of the Supreme Court of Queensland in R v. LM  QCA 192 at paragraph 62 and 66. I take full account of the criminal law and foreign jurisdictional contexts of that decision but I am persuaded by the following argument upon its face that it is valid to the English law of evidence as applied to children proceedings.
The terms "Munchausen syndrome by proxy" and "factitious (and induced) illness (by proxy)" are child protection labels that are merely descriptions of a range of behaviors, not a pediatric, psychiatric or psychological disease that is identifiable. The terms do not relate to an organized or universally recognized body of knowledge or experience that has identified a medical disease (i.e. an illness or condition) and there are no internationally accepted medical criteria for the use of either label.
In reality, the use of the label is intended to connote that in the individual case there are materials susceptible of analysis by pediatricians and of findings of fact by a court concerning fabrication, exaggeration, minimization or omission in the reporting of symptoms and evidence of harm by act, omission or suggestion (induction). Where such facts exist the context and assessments can provide an insight into the degree of risk that a child may face and the court is likely to be assisted as to that aspect by psychiatric and/or psychological expert evidence.
All of the above ought to be self evident and has in any event been the established teaching of leading pediatricians, psychiatrists and psychologists for some while. That is not to minimize the nature and extent of professional debate about this issue which remains significant, nor to minimize the extreme nature of the risk that is identified in a small number of cases.
In these circumstances, evidence as to the existence of MSBP or FII in any individual case is as likely to be evidence of mere propensity which would be inadmissible at the fact finding stage (see Re CB and JB supra). For my part, I would consign the label MSBP to the history books and however useful FII may apparently be to the child protection practitioner I would caution against its use other than as a factual description of a series of incidents or behaviors that should then be accurately set out (and even then only in the hands of the pediatrician or psychiatrist/psychologist). I cannot emphasis too strongly that my conclusion cannot be used as a reason to re-open the many cases where facts have been found against a carer and the label MSBP or FII has been attached to that carer's behavior. What I seek to caution against is the use of the label as a substitute for factual analysis and risk assessment.
In his book Playing Sick (2004), Marc Feldman notes that such findings have been in the minority among U.S. and even Australian courts. Pediatricians and other physicians have banded together to oppose limitations on child-abuse professionals whose work includes FII detection. The April 2007 issue of the journal Pediatrics specifically mentions Meadow as an individual who has been inappropriately maligned.
The book Sickened, by Julie Gregory, details her life growing up with a mother suffering from Munchausen by proxy, who took her to various doctors, coached her to act sicker than she was and to exaggerate her symptoms, and who demanded increasingly invasive procedures to diagnose Gregory's enforced imaginary illnesses.
Lisa Hayden-Johnson of Devon was jailed for three years and three months after subjecting her son to a total of 325 medical actions – including being confined to a wheelchair and being fed through a tube in his stomach. She claimed her son suffered from a long list of illnesses including diabetes, food allergies, cerebral palsy and cystic fibrosis, describing him as "the most ill child in Britain" and receiving numerous cash donations and charity gifts, including two cruises.
In the mid-1990s, Kathy Bush gained public sympathy for the plight of her daughter, Jennifer, who by the age of 8 had undergone 40 surgeries and spent over 640 days in hospitals for gastrointestinal disorders. The acclaim led to a visit with first lady Hillary Clinton, who championed the Bushs' plight as evidence of need for medical reform. However, in 1996, Kathy Bush was arrested and charged with child abuse and Medicaid fraud, accused of sabotaging Jennifer's medical equipment and drugs to agitate and prolong her illness. Jennifer was moved to foster care where she quickly regained her health. The prosecutors claimed Kathy was driven by Munchausen Syndrome by Proxy, and she was convicted to a five-year sentence in 1999. Kathy was released after serving three years in 2005, always maintaining her innocence, and having got back in contact with Jennifer via correspondence.
In 2014, 26-year-old Lacey Spears was charged in Westchester County, New York, with second-degree depraved murder and first-degree manslaughter. She allegedly fed her son dangerous amounts of salt after she conducted research on the Internet about its effects. Her actions were allegedly motivated by the social media attention she gained on Facebook, Twitter and blogs. She was convicted of second-degree murder on March 2, 2015, and sentenced to 20 years to life in prison.
Munchausen directed towards animals
Medical literature describes a subset of MSbP caregivers, where the proxy is a pet rather than another person. These cases are labeled Munchausen syndrome by proxy: pet (MSbP:P). In these cases, pet owners correspond to caregivers in traditional MSbP presentations involving human proxies. No extensive survey has yet been made of the extant literature, and there has been no speculation as to how closely MSbP:P tracks with human MSbP.
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